R.D. Keene Family Professor and Chairman
Department of Neurological Surgery
University of Florida
AANS Member Since 1969

Figure 1. Studies of the microsurgical anatomy of the ventricles, the intracranial vasculature, and the skull base.

Figure 2. The Theodore Gildred Microsurgical Laboratory at the University of Florida, where seven surgeons could participate in microsurgery courses.

Figure 3. Set of 19 microsurgical dissectors are now used worldwide.

Figure 4. The first set of round handled bayoneted bipolar forceps and microscissors.

The earliest use of micro-operative techniques in neurosurgery occurred near the time that I was completing residency training in 1965. My first use of the operating microscope was during an NIH research fellowship in 1965. The goal of that research project was to trace the pain-bearing afferents of the cranial nerves. The operating microscope was used for the surgery in small animals and, during this period, it was realized that the surgical microscope was capable of revealing previously unreported details of neuroanatomy, the knowledge of which could improve the outcome in operations for tumors and aneurysms. It was at that point that we began our studies of microsurgical anatomy. The studies in the years since then have resulted in more than 200 publications dealing with the microsurgical anatomy of the intracranial structures and skull base. These include studies of the microsurgical anatomy of the ventricles, the intracranial vasculature, and the skull base (Fig. 1). Recent studies have focused on the orbit, temporal bone, and cavernous sinus. Many surgeons feel that the method in which these studies have been presented provided the anatomic basis for the development of skull base surgery and improvements in aneurysm and tumor studies. The studies have led to the development of some new operative approaches to the ventricles and skull base. Some of the earlier studies provided the first photographic display of the five nerves in the internal acoustic meatus.

Soon after embracing microsurgery as an essential component of our neurosurgical practice, it became obvious that there were several generations of surgeons who needed training in these techniques. This led to the development of the Theodore Gildred Microsurgical Laboratory at the University of Florida, where seven surgeons could participate in microsurgery courses (Fig. 2). More than 1,000 neurosurgeons, seven at a time, attended microsurgery courses at the University of Florida.

The early efforts at training and applying micro-operative techniques led to the realization that the neurosurgical instruments suitable for macrosurgery done with the naked eye were not satisfactory for microsurgery done using the operating microscope. This led us to develop numerous sets of instruments which had special applications in microsurgery.1,2 A set of 19 microsurgical dissectors developed in response to this need are now used worldwide (Fig. 3). During the early performance of superficial temporal to middle cerebral artery anastomosis, it was realized that the then available needle holders and scissors were too large for this delicate operation. A set of instruments was then developed for microvascular anastomosis. These instruments are now used in multiple specialties for microvascular surgery. The instruments developed for microvascular suturing had round handles, thus making it easier to rotate the instrument between the thumb and index finger rather than having to rotate the whole wrist or arm that was necessary when flat handled instruments are used. This led to the development of the first set of round handled bayoneted bipolar forceps and microscissors (Fig. 4). Much of the instrument development was done in cooperation with Mr. William Merz, who is now nearly 90 years of age, and who recently made a decision to endow a Chair in Neurological Surgery at the University of Florida. Other sets of instruments which have gained wide use which were developed in cooperation with Mr. Merz include atraumatic blunt tip suction tubes, ring curettes for transsphenoidal surgery, microrongeurs, and a self-retaining brain retractor system.

An early trend was to use one set of instruments for macrosurgery done with the naked eye and a different set for microsurgery done with the operating microscope. A recent trend is to develop sets of instruments which have the same type of handles but with different tip sizes so that instruments with the same balance and feel can be used for both macro- and microsurgery. The instruments are adjusted for the different types of surgery by having different tip sizes. Although microsurgery has become a standard part of every neurosurgeon's armormentarian, there are still many research and other opportunities to improve micro-operative techniques in neurosurgery. There remains many areas where our knowledge of microsurgical anatomy must be enhanced and for which new and specialized instruments are needed. We are still in the infancy of marrying the operating microscope to image guided techniques. The first of a number of operating microscopes which wed microsurgery and image guiding techniques have appeared. These techniques provide the neurosurgeon with information regarding the relationships of the focal point of the lesion he is seeing under the operating microscope with exact anatomic information about the site of the lesion as seen on CT and MRI. The twentieth century saw the birth and incorpo-ration of microsurgery into every neurosurgeon's practice. As we approach the new millennium, there are still many exciting new opportunities to extend our knowledge of microsurgical anatomy and micro-operative techniques to improve the lives of our patients.